Admissions Prevention & Facilitated Discharge Service Evaluation

Transcription

1 Admissions Prevention & Facilitated Discharge Service Evaluation Final report, February 2013 Applied Health and Wellbeing Partnership The Applied Health and Wellbeing Partnership The Applied Health and Wellbeing Partnership is an initiative of NHS Wirral Research & Development Team and Liverpool John Moores University Centre for Public Health. The Partnership supports the development, delivery and evaluation of the Wirral Health and Wellbeing Strategy, through the innovative generation and application of evidence for effective and sustainable health and wellbeing commissioning. 1

2 Acknowledgments The authors of this report would like to thank Maggie Johnson and Joanne Stewart for all their help in recruiting research participants for this service evaluation, and Paul McGovern for his support and assistance. The authors would like to also thank members of the Applied Health and Wellbeing Partnership for their support during this evaluation. Finally, the authors would like to thank and acknowledge all of the participants involved in this evaluation for sharing their views and experiences with us; in particular, family members of patients. 2

3 Admissions Prevention & Facilitated Discharge Service Evaluation Final report, February 2013 Contents Acknowledgments... 2 Executive summary Introduction The APFD service Methodology Healthcare professional interviews Family interviews Results Healthcare professional interviews Difficulties faced by healthcare professionals Experiences of the APFD service Impact of the service The prevention of hospital admissions Facilitated discharge Successful attributes of the APFD service Recommendations/Suggestions Family interviews Perceptions of service need Service response Impact on the patient Impact on the family Perceptions of life without the APFD service Service experience Recommendations/Suggestions Case studies Summary of findings References

4 Executive Summary Over 70% of hospital bed days are occupied by emergency admissions, and over 80% of emergency admissions who stay for more than two weeks are patients aged over 65. Older people are the main adult users of NHS health and social care services, at any one time occupying more than two thirds of acute hospital in-patient beds. Understanding and preventing avoidable admissions is a pressing issue, especially with NHS budget restraints, an increasing ageing population, and the demand for care closer to home. Research highlights current issues in the care of the elderly in acute settings such as: the high rates of admissions that could be avoided, the exposure to harmful risks in hospital settings, the high rates of readmissions that could have been avoided, delays in hospital discharges, and an overall lack of integrated care for the elderly. These factors have a large impact upon hospital admission rates and length of stay, and can also impact the elderly patient adversely. Research illustrates that there is a significant need for services that provide effective interventions for the elderly that prevent hospital admission, readmission and reduce length of stay. Alternative settings, such as care within the community, have been found to be more appropriate than an acute setting for some elderly patients; yielding similar outcomes to hospital stays at a reduced cost, whilst enabling individuals to maintain their independence and remain in a familiar environment. Timely and appropriate interventions can reduce risk and also maintain independent living. Integrated care approaches have been found to reduce the utilisation of hospital based services and result in lower readmission rates for both elderly patients and those with long term conditions. The Admissions Prevention and Facilitated Discharge (APFD) service aims to reduce the incidence of hospital admissions and facilitate a timely supported discharge process for those that are admitted into hospital. The service provides interventions such as increased packages of care within the patient s home, rapid access to respite and twenty four hour care nursing beds, access to therapies (e.g. physiotherapy, occupational therapy), facilitation of early supported discharge from hospital into alternative community settings, and the service also supports patients into long term care placements where necessary. The AFPD service has been evaluated in the following report in order to explore the impact of the service upon the patient journey. The views and experiences of healthcare professionals (who refer patients or deliver the service to patients) and family members of patients (who had recently used the service) were elicited for the evaluation. A qualitative method was developed using semi-structured interviews with a case study approach employed for patients family members. Thematic analysis was conducted on the data generated, identifying and summarising main themes. Case study examples are also presented to illustrate the impact of the APFD service upon patients (as elicited from family members). Overall findings from healthcare professional and family members were then triangulated; with the main themes presented in a final summary. All participants felt the APFD service had prevented hospital admissions for patients by providing rapid interventions at a critical point. The APFD service had accomplished this by increasing packages of care within the patient s home, arranging for rapid access respite and twenty four hour nursing beds, arranging for access to therapies (e.g. physiotherapy) and arranging long term care placements. In some instances, participants spoke of the APFD service reducing hospital length of stay for patients by facilitating an earlier supported 4

5 discharge into an alternative setting (such as temporary respite in a residential care setting/nursing home). Findings revealed that both healthcare professionals and family members faced significant difficulties when trying to support an elderly person/patient, experiencing problems when trying to access and arrange community support before the APFD service was made available to them. All participants spoke of the positive impact that they felt the APFD service had upon them (both family members and healthcare professionals) and of their positive experience of the service. In particular, the APFD service was praised for its accessibility and its rapid response for patients in crisis. Participants stated that the rapid response of the APFD service filled a gap that they felt existed in the healthcare services for older patients, and spoke of how the service helped overcome the problems they had initially experienced before coming into contact with the service. The service was also commended by participants on its ability to give personalised, integrated care to patients and their family members, with family members emphasising the quality of support that they themselves had received as carers at such a difficult time. The knowledge and experience of the staff, and their ability to effectively co-ordinate care for the patient was highlighted by all participants as a significant advantage of the service, with the view emerging of the APFD as a specialist service for supporting elderly people and their families within their own community. The APFD service is a unique service that provides rapid effective interventions that are demonstrated by research as effective in preventing hospital admission, readmission and in reducing length of stay for patients. The service provides a high impact intervention for both patients and their family members, and is highly recommended by healthcare professionals as an effective service. Rachel Lavin, Health and Wellbeing Research Assistant Dr Hannah Smith, Health and Wellbeing Researcher Applied Health and Wellbeing Partnership, Centre for Public Health, LJMU 5

6 1. Introduction Older people are the main adult users of NHS health and social care services (Philp, 2007; Age UK, 2012) and are more likely to have an emergency admission to hospital than any other group in the population (Blunt, Bardsley & Dixon, 2010). Understanding and preventing avoidable admissions is a pressing issue, especially with NHS budget restraint, an ageing population, and the demand for care close to home (Mytton et al., 2012). The number of older people within society is set to increase; by 2032, it is estimated that 27% of the Wirral population will be aged 65 or above. With an increasing ageing population, the number of older people presenting with health related problems also increases (Department of health, 2008; Wirral JSNA, 2012) which has significant implications for the NHS. The Government s vision for Adult Social Care (Communities and Active Citizens and the White Paper Equity and Excellence: Liberating the NHS) documents the intended drive towards the personalisation of public services in health and social care, in order for as many people as possible to be able to stay healthy and actively involved in their community for longer. This in turn should potentially delay or avoid the need for targeted services (Department of Health, 2010). Elderly hospital admissions, readmissions and delayed discharges Over 70% of hospital bed days are occupied by emergency admissions, and over 80% of emergency admissions who stay for more than two weeks are patients aged over 65 (The Kings Fund, 2011). Older patients are the main in-patient group, at any one time occupying more than two thirds of acute hospital in-patient beds (Age UK, 2012). Mytton et al. (2012), found a substantial proportion of admissions for the elderly were potentially avoidable, suggesting that avoidable admissions represent a failure to effectively manage long-term conditions. The older patient is three times more likely than their younger counterparts to be admitted to hospital following attendance at an emergency department (Philp, 2007). Emergency admissions to hospital for older people can be a particularly disruptive and unsettling experience, which can also expose them to new clinical and psychological risks (Lafont et al., 2011). When older people are admitted to an acute hospital setting, they are more likely to stay and suffer life-threatening infections, falls and delirium (Philp, 2007), which is damaging to the patient s health and also puts further strain upon acute settings. For example, with older patients with dementia it has been found that the longer the stay in an acute hospital settings, the worse the effect on the symptoms of dementia and the individual s physical health (Alzheimer s Society, 2009). An emergency hospital admission often occurs when an older person has reached a crisis point due to a combination of circumstances (for example due to social circumstances such as caring responsibilities), and often, simply fixing the medical problem does not put the older person back in a position to cope (Age UK, 2012). This has particular implications for the care of elderly patients; if they are not discharged from such settings with the proper support or care management after their hospital admissions they could subsequently be re-admitted at a later date. In the UK, emergency readmissions for people aged seventy five or over increased by fifty percent between and (The King s Fund, 2012). Furthermore, the majority of readmissions have been found to be older patients with complex care needs (Shalchi, Li, Rowlandson & Tennant, 2009). Common causes of patient readmission include inappropriate or incomplete treatment, failure of adequate handover from secondary back to primary care, as well as poor social planning, particularly in the elderly (Van Walveren et al., 2002; Mistiaen, Francke, & Poot, 2007; Witherington, Pirzada & Avery, 2008). 6

7 The King s Fund, 2012, found that Primary Care Trusts with the highest bed use tended to have excessive lengths of stay for patients for whom hospital was a transition between home and supported living. Factors associated with delayed hospital discharges are often related to the care of older patients who have ongoing needs for care and support following their discharge from hospital (Henwood, 2006). For example, people with dementia have been found to stay in hospital much longer than others who have been admitted for the same medical procedure, with recent findings highlighting problems with discharge processes experienced by patients carer s and nurses, such as lack of access to additional support such as a physiotherapist (Alzheimer s Society, 2009). Alternative Settings A recent review of bed use in 32 acute clinical facilities indicated that for approximately 49% of bed days, an alternative setting (i.e. at home with medical services/receiving respite care in a nursing home) would be more appropriate for the patient (The King s Fund, 2012). Provision of these more suitable alternatives for acute hospital admissions can also often result in admission avoidance in acute situations (The King s Fund, 2010). This alternative setting is not only of benefit to patients, but can alleviate the strain acute settings by freeing up hospital beds, allowing more cost effective treatment (The King s Fund, 2011). Furthermore, hospital at home services have been found to produce similar outcomes to inpatient care, at a reduced cost (Shepperd et al, 2009). By providing successful interventions such as community-based health services that aim to prevent hospital admissions and/or reduce length of stay, there will be a reduced need for acute hospital care (Philp, 2007; Age UK, 2012). Healthcare professionals currently involved in NHS services aiming to reduce hospital admissions felt that increased rapid-access homebased care and support services, the expansion of intermediate care services, case management of those with chronic conditions at risk of hospitalisation and improved discharge planning within acute hospital settings, were likely to a have high impact upon hospital admissions (Department of Health, 2012). Integrated Care The management of care for frail older people and those with long term conditions has been found to work best within a wider programme of care whereby multiple strategies are employed to integrate care. For example, utilising an integrated care approach that provides effective access to primary care services, access to multidisciplinary assessment, health promotion and prevention, and actively co-ordinates community-based packages for rehabilitation and re-ablement, has been demonstrated to have positive impacts on patient outcomes (Jerram, 2010; The King s Fund, 2012). Together these multiple strategies improve the experiences of users and carers, support better care outcomes, reduce the utilisation of hospital-based services and enable a more cost-effective approach to care (The King s Fund, 2011). Areas in the UK that have well-developed, integrated services for older people have both lower rates of hospital bed use and lower readmission rates, and also have been found to deliver a good patient experience (The King s Fund, 2012). An increased supply of social care services can contribute to a reduction in aggregate societal costs of the treatment and nursing of elderly patients by shortening a comparatively costly hospital length of stay (Holmas, Islam, & Kierstad, 2012). Therefore, it is recommended that any local strategy aligns ways of working between primary, community and acute care services to reduce avoidable admissions and length of stay in hospital (The King s Fund, 2012). Working across the health and social care boundary is an important factor in reducing postinpatient discharge readmission rates (Parker et al., 2002), and readmissions can potentially be avoided with judicious medical care (Shalchi et al., 2009). Hospital length of stay for 7

8 elderly patients has been found to depend on the interaction with long term care services and the organisation and resources utilised in this sector (Holmas, Kjersted, Frode & Luras, 2007). Facilitated discharge planning has been shown to be effective in reducing the length of hospital stay and preventing readmission into hospital (The King s Fund, 2010). Furthermore, medical issues dealt with in unison with social rehabilitation, can in turn improve confidence, motivation and social engagement and provide a seamless, united clinical rehabilitation (Age UK, 2012). Research recommends that elderly patients and those with long term conditions should be provided with multidisciplinary assessment in order to provide effective holistic support (Jerram, 2010). Mytton et al., 2012 note how often the care of elderly people depends on high quality clinical decision making in order to successfully address complex care needs. The discharge or transfer of care of these more complex patients requires the experience and skills of several professionals from a range of different organisations, and without careful coordination this process can disintegrate to the detriment of the patient and their family (Jerram, 2010). Personalised Care Involving patients and carers in decision making enables them to make informed choices that delivers a personalised care pathway, and can support the communication process between multiple agencies and give control to the individual regarding their own information (Scottish Government, 2009; Department of Health, 2010). Similarly, working with the patient, carers and significant others involved in the patient s care is essential to ensuring seamless services, whilst aiming to avoid repetition, inappropriate treatment, gaps in treatment and harmful outcomes (Jerram, 2010). Philp, (2007), recommends providing individual nursing care and advice in order to help older people and their families/carers, and to maintain their independence. Anticipating and co-ordinating care needs of patients is noted as key to better management of the large amount of older people with chronic conditions (Philp, 2007). Structured discharge planning is also effective when addressing older people s care needs, with readmissions being significantly reduced for patients allocated to personalised discharge planning (Shepperd et al., 2009). Rapid Response Enabling timely and appropriate interventions can reduce risk and also enable the maintenance of independent living (Jerram, 2010; Mundy et al., 2003). Focused timely bursts of therapy, intermediate care or homecare have been found to prevent hospital admission by maximising long-term independence, which in turn appropriately minimises ongoing support (Department of Health, 2008). Philp, (2007), recommends that early supported discharge should be enabled whenever possible with care delivered closer to home in the patient s community to maintain independence, to help them regain their confidence and also to reduce the risk of the older person of acquiring infections and other complications. Additionally, early intervention in dementia care has also been shown to help sufferers and their families enjoy a higher quality of life and reduce the need for admission to care homes (Alzheimer s Society, 2009). Similarly, improving diagnosis and treatment of patients with delirium and dementia can reduce lengths of stay in hospital (Lundstrom et al., 2005). Summary The general literature indicates that there is a significant need for services that provide effective interventions for the elderly that prevent hospital admission, readmission and 8

9 reduce length of stay. Providing care in alternative settings (e.g. the home environment or a residential placement) enables the patient to remain in their community, reduces the need for care in acute settings, and has been found to yield similar outcomes to inpatient care at a reduced cost. An integrated care approach has been demonstrated to be beneficial for the elderly and those with long term conditions, and has been found to reduce the utilisation of hospital based services and also result in lower readmission rates. Facilitating supported discharge and effective transfer of care for patients reduces readmissions rates and length of stay in hospital. Involving the patient and those involved in their care can avoid repetition, inappropriate treatment, and harmful outcomes. Furthermore, timely and appropriate interventions can reduce risk and maintain independent living. 1.2 The APFD service The Admissions Prevention and Facilitated discharge (APFD) service is a service specific to Wirral, implemented in 2011, that aims to reduce the incidence of hospital admissions and also aims to facilitate a timely supported discharge process for those that are admitted into hospital. Prior to the service being developed, Wirral commissioning consortium identified that demands on Social Services and Community Therapies led to delays in the provision of packages of care, adjustments, or equipment required to support patient re-ablement at home. The consortium also recognised the need for a preventative approach to identify why certain patients were admitted to hospital, and the types of conditions requiring hospital admission. The APFD service is hosted and delivered by two General Practices co-located at a medical centre. A Senior Nurse Clinician was initially recruited to develop and deliver the project in February 2011 for 25 hours per week supported by full administrative support. The Senior Nurse Clinician works closely with health and social care Multi-Disciplinary Teams to support case management approaches to patient care. Patients are referred to the APFD service by health care professionals such as their GP, a District Nurse or a social worker. Within the first six months of service implementation, the Senior Nurse Clinician had received and case managed 162 individual patient episodes. A review presented to the Wirral GP Clinical Commissioning Group in November 2011 identified that respite packages, home care placements, and access to therapies and equipment had prevented hospital admission in over 45% of referrals. Analysis of service data by the Wirral Performance and Intelligence team demonstrated potential cost savings of 127,000, which did not include potential savings from A&E attendance or Ambulance costs. In response to these positive findings, the Senior Nurse Clinician post was increased to full time in January and the project had received 334 referrals by the end of the first full year. In addition, another local Clinical Commissioning Group has recently invested to provide this service to their patient population. The APFD service provides interventions such as increased packages of care within the patient s home, rapid access to respite and twenty four hour care nursing beds, arranging prompt access to therapies (e.g. physiotherapy and providing necessary adaptations within an individual s home), facilitating supported discharge, and the service also arranges long term care placements within nursing homes where necessary. These interventions are provided with an aim to prevent acute crises from occurring that require a hospital admission, to support individuals to maintain themselves within their community for as long as they are able, and to facilitate a supported, timely discharge if individuals are admitted into hospital. The most common cause of referral to the APFD service during the period of April 2011 to September 2011 was for fall, chronic obstructive pulmonary disease, and dementia (Exemplar Project Submission, 2011); with the typical user of the APFD service being an older patient. 9

10 Evaluation Research by the NHS Wirral Performance and Intelligence Team has demonstrated the potential cost-effectiveness of the APFD service. However, qualitative explorations of how this service has impacted the patient journey are required to support the effectiveness of this spend. Therefore, the Applied Health and Wellbeing Partnership (AHWP) were requested to undertake a qualitative evaluation to explore the perceived impact of the APFD service on the patient journey. 10

11 2. Methodology A qualitative method was used to explore the impact of the APFD service, with data collection and analyses taking place between January and February An application was made to Liverpool John Moores University Research Ethics Committee prior to the commencement of the evaluation to review the ethical implications of the proposed participant recruitment and data collection. The evaluation design and methods were approved as being ethically sound in December 2012 (ethical approval reference number 13/HEA/005). The evaluation design, participants and topics for interview discussions were developed in liaison with the Wirral GPCCG Commissioning Support Manager with responsibility for the APFD service. 2.1 Healthcare professional interviews Semi-structured telephone interviews were conducted with healthcare professionals involved in either the delivery of the service, or in referring to the service. Interviews took place between the 16 th and 31 st January The APFD business manager identified the different healthcare professionals involved in the service, and made prior contact with these professionals, advising them of the service evaluation, and disseminating study Participant Information Sheets. The business support manager then provided the evaluation team with contact details of those healthcare professionals who consented to take part in the evaluation, and the research team then made contact with these individuals to complete a telephone interview. To ensure a representative reflection of the APFD service eight healthcare professionals were interviewed: three General Practitioners (GPs) from different practices who were involved in referring into the service, three professionals directly involved in the delivery of the APFD service consisting of a Health Care Assistant, an Advanced Nurse Practitioner and an Administrative Support, and two professionals involved in providing support services for patients referred to them through the APFD service consisting of a Social Worker and a Head of Community Therapies. One of the GPs interviewed was from the practice that hosted the APFD service and had been associated with the development of the APFD service. The eight various healthcare professionals were separately interviewed over the telephone in order to explore: the impact of the service upon healthcare professionals work, the perceived impact of the service upon the patients, family members and carers, and ways (if any) in which they felt the service could be improved. The interviews lasted approximately minutes and all participants provided written consent before the interview commenced, and gave permission for the telephone interview to be audio recorded. The interviews with each healthcare professional were then transcribed and thematically analysed by the evaluation team. 2.2 Family interviews Semi-structured case study interviews were conducted with the significant others/carers of patients who have used the APFD service. Interviews took place between the 25 th January to the 8 th February The Lead Senior Nurse of the APFD service identified the significant others of patients who had recently used the APFD service, and made prior contact with these individuals, advising them of the service evaluation, and disseminating study Participant Information Sheets. These people were given a week to read the information sheets and decide if they would like to take part. The Lead Senior Nurse provided the evaluation team with contact details of people who had consented to take part in the 11

12 evaluation. All significant others/carers of patients interviewed were related to the patient; therefore they are referred to throughout the report as family members. Case study participants included sons, daughters and daughter-in-laws of patients. The number of people included in each interview was not prescribed but was determined instead by the preference of each patient s family member. Case study interviews in some instances were undertaken with more than one family member present, if there were a number of people involved in caring for or supporting a patient. All of the case study interviews were completed within family members homes; with the exception of one interview taking place via the telephone. Two researchers from the evaluation team were present for each of the home interviews. In total, seven family members were interviewed within the five interviews conducted. Three interviews were completed with one family member present (on a 1-1 basis), and two interviews were completed with two family members present (a paired interview). Therefore, five different patient s journeys were described in total by their family members. Interviews explored: experiences of the service, the impact of the service upon the patient, the impact of the service upon them as significant others/carers, and ways (if any) in which they felt the service could be improved. The semi-structured case study interviews lasted between minutes and all participants provided written consent to take part and have the interview audio recorded, before the interview commenced. The interviews with patient s family members were then transcribed and thematically analysed by the evaluation team. 12

13 3. Results 3.1 Healthcare provider interviews The main themes that emerged from the data were difficulties faced by healthcare professionals, experience of the APFD service, impact on the service, prevention of hospital admission, facilitated discharge, successful attributes of the APFD service (integrated, personalised care, rapid response: filling a gap and specialised service) and recommendations/suggestions Difficulties faced by healthcare professionals The majority of healthcare professionals interviewed spoke in detail of current issues that they felt were prominent in the care of elderly patients, particularly with regard to the difficulty of accessing alternative services. All GPs felt that before the APFD service was available it was difficult for them to try and co-ordinate and access care for elderly patients who needed urgent support, noting how this difficulty often resulted in patients being admitted to hospital due to lack of other more appropriate available options. Similarly, many participants spoke of how they felt an acute setting was detrimental to the elderly if their needs could be met within their community. Some healthcare professionals described how they felt that acute settings in these cases could result in institutionalisation and increased dependency. Another participant felt that elderly patients with complex needs were often avoided by some healthcare professionals, which resulted in an increased demand for the APFD service. Sometimes you feel like you ve got to jump through so many hoops to get a response. before that, we used to spend next to a day trying to get things in place in an urgent placement; it never happens So then the default is; that person is unsafe at home and the only safe place is at hospital so they get admitted and I know it s wrong, the patient knows it s wrong and the hospital knows it s wrong, but it s all that s left. the default position historically had been hospital admission because as a GP you didn t really have any other option and social services tended not to be able to respond quickly enough. the acute hospital setting I don t think is appropriate because you don t sleep, you don t rest properly You need somewhere quiet and more personalised care which they can t always provide in an acute hospital setting. if you are put in an acute ward at a really busy time of year you are not going to receive the care there just isn t the staffing ratio for people s needs. you often find with elderly, when they re on the ward they tend to deteriorate really quickly and that s mentally as well their mobility goes down. So they tend to come out a lot more physically unwell than when they went in. People can become institutionalised it can de-skill, create more dependency these patients; everyone else avoids and that s why their hitting our services because they ve got so many complex problems that people are just avoiding them. Many of the healthcare professionals also expressed their concern with the quality of hospital discharges for patients with ongoing health and social needs, whereby patients needs were often not fully met. Participants spoke of how this could result in people losing trust in health 13

14 professionals due to poor discharges, and how initial medical problems can reoccur if the needs of the patient are not managed after hospital discharge. the hospital they don t fully understand the needs of the patient and what is needed to manage them in the community And we know that because they send them out of hospital without equipment and their needs aren t fully met at home. With poor hospital discharges people have lost trust in the health professionals we tend to pick up a lot of that I think there are problems with hospital discharge I m concerned about the level of skill that manages hospital discharge from the hospital. if they don t get it sorted properly on the first time then the same problems is just going to come back and they re going to have to go through that awful journey again. we find that the hospital discharges are not well thought out there s poor information. If there is a negative on Wirral; it s the quality of hospital discharges you get discharges that aren t safe because things haven t been put in place by secondary care before they are discharged Experiences of the APFD Service All healthcare professionals felt that referring to the APFD service was straightforward. GPs who referred the service particularly felt this was a very easy simple process, with one GP explaining how they enjoyed being able to phone and speak to someone at the APFD service who would discuss the referral with them. I like the way you can phone. I think that s brilliant because there s usually someone there to discuss it with you. I ve been nursing twenty years and it is probably the easiest referral system that I have ever known. it s been a phone call really and that s how easy it is. All healthcare professionals spoke at great length about their positive experiences of the APFD as a service, with those who referred into the service highlighting how important and beneficial they felt the service was. Similarly, those who dealt with the referrals and those involved in providing services with APFD spoke of the professionalism of those within the service and of the need for such a service in Wirral. I find it extremely useful; it s probably one of the most beneficial services that has been developed. I think it s an excellent service they do a great job it is a really good service; we really wouldn t want to lose it! They always respond positively. you have the confidence that that problem will be sorted. they have been very positive and very professional. 14

15 Furthermore, those involved with the delivery of the service spoke of the personal satisfaction they received from working for the service. I am really proud to work for the service. I enjoy coming into work because at the end of the day I know we are actually helping people. I feel that this job is more rewarding because I feel like I ve got more time to spend with them [patients] and to find out what their needs are Impact of the service All healthcare professionals involved in using or delivering the APFD service spoke of the positive impact they felt service had upon the patients who used it. GPs and APFD service providers spoke of the positive feedback they had received of the service. Many spoke of the fact that the APFD enables patients to make informed choices by offering alternatives to acute hospital settings, and also of how the service provides patients with information to services available to them of which they may have been previously unaware of. It s having a positive impact we tend to get really positive feedback from the patients. I have had very good responses from patients, verbally. They are very grateful. Most patients I ve been out to see have been really pleased about the service. it s quite a positive experience, because it s empowering people them at home. We help them by giving them a better understanding of what s out there for them. It gives them choice because before the patient really only had a choice to go into hospital So this offers an alternative way of supporting the patient s needs without, which can be quite unsettling for people, having to go into hospital. it s about choice, it s about meeting the need sooner it s enabling patients to receive treatment where they would prefer. it s helping them when they ve got nowhere else to turn to Healthcare professionals also spoke of the positive impact they felt the service had upon family members/carers of patients. Participants spoke of the large impact the service had when intervening and providing support to families/carers experiencing a crisis. This was achieved by listening and responding to the families needs or concerns, and by providing support such as an increased care package within the home or by arranging respite. Those involved in referring and those involved in the delivery of the APFD service highlighted the positive feedback they had received from family members and carers who had been involved with the APFD service, and felt that the service alleviated stress and gave families peace of mind at a potentially difficult time. 15

16 I have not had any negative sort of comments at all about the service from relatives and patients; they ve all been really happy with what s been provided for them. we have had a lot of thank you s from family members. family members, who have been struggling, they ve been very grateful when we have stepped in and helped out It is supporting carers, family members. it is offering support to families it reduces the stress on the families and carers because they know that somebody is coming in to assess the problem and they are putting solutions in place. it gives the family peace of mind when they are struggling. they know that they are being looked after and that they are safe. it has alleviated a lot of stress it s a support mechanism. [the APFD service] always give the respect that everyone s fully involved, so the family don t feel out of the loophole. A lot of people don t know where to turn to when things are starting to get bad with their family member All healthcare providers felt that the APFD service was providing an invaluable service for families and patients, and believed there would be increased stress and pressure upon family members and carers if the APFD service was not available. They felt this would result in more crises and have detrimental consequences such as the health conditions of carer s worsening and increased time off work for family members and carers. All healthcare providers also felt without the APFD there would be an increase in hospital admissions and increased pressure upon GPs. For all the healthcare professionals, the service appeared to address a lot of the difficulties they spoke of as being prevalent in health care for the elderly (see section 3.1.1). I think there would be more time off work and that stress and family life and so on and their own health conditions have potential for worsening as well so there s lots of indirect things that can have a knock on effect. I think there would be a lot more hospital admissions, and a lot more people left alone. They would probably just struggle on and not know where to get help and then that s more pressure on the family GP then. I just think it would be really sad because then the majority of people would end up in hospital. GPs involved in referring patients to the service emphasised the large positive impact they felt the APFD had had upon their work. GPs felt the service had alleviated the strain they felt when trying to co-ordinate social and health care services for patients with complex needs, whilst also trying to maintain their usual patient case loads. They explained how they the 16

17 service was very helpful in saving them time, which had enabled them to provide effective support for their other patients. it s certainly saved me time because they will access the care agencies that have got vacancies. It s less stress for me they have just taken that whole stress and strain away which is a godsend! it certainly makes life much easier for GPs to get somebody into respite it allows me to get on with the other patients that I am dealing with. The other healthcare professionals involved in the delivery of the service and those working alongside the APFD service involved in providing support services, spoke of how the service was expanding rapidly and explained how this had increased their workload. Those involved in the delivery of the service felt they would benefit from additional staff to maintain the rapid access and good quality of care for patients that the APFD currently provides, and also to support staff. its increased workload for everybody. it has actually put quite a pressure on services it s getting that busy now that we could do with more staff. We could do with more staff we definitely need more staff. All healthcare professionals felt that they had built good professional working relationships with other healthcare professionals as a result of the APFD service, which they felt provided a more integrated patient approach with GPs, health and social care working together better. They felt the service linked in effectively with other services, and helped facilitate a team approach to patient care. All healthcare professionals felt they also had good working relationships with those involved in the delivery of the APFD service. we have built up really good relationships with them. with Admissions Prevention I have built such brilliant professionals relationships. we communicate.we have a two way conversation about the patient. So I feel it s very much a team involvement. There s more multi disciplinary working and a closer working relationship with health. It s multidisciplinary working there; getting everybody on board the service is a lot more communication, there s a lot more face to face and a lot more working together you are working with other people so you ve got other people helping you all working together for the one person. 17

18 3.1.4 The Prevention of Hospital Admissions All healthcare providers unanimously agreed that the APFD service prevented hospital admissions, and helped prevent acute crises for both patients and carers. Participants spoke how they felt that the majority of cases that were referred to the APFD service would have resulted in a hospital admission had the service not intervened. Healthcare providers emphasised that the short-term packages of care that the APFD service provides are able to address people s health needs more appropriately within their own community. This was felt to provide good patient outcomes, and gave patients the option to be treated within their community, which many patients preferred. It is certainly keeping them out of hospital. they are avoiding hospital admission. it helps to prevent a crisis. And it s usually the crisis that results in them needing admission. it s preventing hospital admissions for those that don t want to be admitted. they would end up in a hospital bed but we can offer them the journey at home or in respite. I would genuinely say that 99% of patients would be admissions if we didn t intervene I genuinely think these patients were just admitted to hospital before! If it s a care crisis at home, it could be that the carer s become ill, then I think intervention by the Admissions Prevention team to actually highlight that and be able to commission a short term package of care at home keeps everybody at home. It s not just impacting on the patient it might have an impact on the person providing care so I think in those cases it might prevent two hospital admissions They are avoiding hospital admission and trying to maintain their independence at home. it s providing all that they need without that trip to hospital. You find with lots of old people, the last thing they want to do is go to hospital. it s the step up that patients need to give them the choice that actually they don t need to go to hospital to have their needs met Facilitated Discharge All healthcare professionals involved in the APFD service delivery, and also those providing support services for patients that were referred into their services through the APFD, felt the service facilitated an earlier, more unified discharge process. They spoke of different cases whereby the APFD service had intervened and facilitated a hospital discharge, which had resulted in a shorter stay and had supported the transition from the acute setting back into the community. Two of the GPs had less experience with facilitating discharge for patients with the APFD service, but did mention some instances whereby they had contacted the APFD service if they felt a patient had been in hospital for too long. In these cases, the APFD had then intervened and facilitated discharge. 18

19 If it s teetering on that the patient needs to be admitted, we speak to one of the consultants get them up there for all the diagnostic tests and if we can manage in the community we send them back out, for us to manage them. Yes definitely facilitating a more speedy, more timely discharge from hospital. We have the hospital discharge team; now they re more so now contacting us [the APFD service] if they have a patient that is medically fit to see if we [the APFD service] can try and get that patient out Successful attributes of the APFD service: Integrated Personalised Care All participants emphasised that the APFD provided personalised holistic care that was of high impact, especially as many of the patients referred had ongoing complex needs to be addressed. Those involved in the delivery of the service spoke of the importance they placed on patient orientated care, and also spoke of how they were willing to take on and manage complex cases. Healthcare professionals commended how the service assesses patients carefully and spends time listening and responding to the needs and concerns of the patient and their family. Additionally, the ability to co-ordinate a care package that enabled the patient access to re-ablement services such as physiotherapy was highly regarded, with healthcare professionals speaking of how the APFD had built the necessary pathways in order to co-ordinate care for patients with multiple needs. Participants spoke of how they felt the service looked holistically at their patients needs and concentrated on the longevity of the patient s care management, and spoke of how the APFD service was able to provide an integrated approach by uniting services on behalf of the patient. Healthcare providers also spoke of the benefit of providing more care in the community rather than in an acute environment, which they felt helped patients recover quicker and enabled them to feel comforted by addressing their needs within a familiar environment. that s the beauty of it; it s for that person, you know. it s individualised to that person s needs. the patient comes first. I think the ethic behind the team is it s going the extra mile and looking at all their needs. it s not task orientated; the patient is taken in as a whole and it s the longevity of their management that s taken into account. we are very willing to take on the complex ones each time we take on a complex case we learn more connections. they have time to come out and assess the patient, and have time to respond and hear their needs and concerns, of not only the patient but often the family as well. it s accessing all areas. I think they [the APFD service] pull the different strands of healthcare. They provide an intervention that is more joined up. they have identified if someone needs equipment or physio; then that service is available for them to utilise as well. 19

20 you are putting them in their home environment, they feel safe, all their friends can come and visit and then you are returning them to their normal health limits. They can stay within their own community or at best they can stay at home. If somebody s quite weak and not well with an admission to a home for a couple of weeks, they can be nursed individually rather than going into a hospital where they are in a ward when there s staff overworked. if you send a care package in; they tend to respond quite quickly. [the APFD service] enhances the care that patients get in the community. Rapid Response: Filling a Gap Many healthcare professionals noted that an advantage of the APFD service was their rapid response and assessment of patients and carers in crises. This enabled a successful timely intervention that avoided a hospital admission, delivered higher patient satisfaction and resulted in a quicker patient journey. Healthcare professionals also mentioned how a quick response was often needed to prevent the situation from deteriorating, and noted that the fact this service provides such a rapid response, compared to the usual route of patients going through their GP and their GP assessing and coordinating care, was a large benefit. In turn, the rapid effective response of the APFD service seemed to address a lot of the problems that healthcare professionals initially raised as issues (see section 3.1.1) in the care of elderly patients. they respond rapidly. they re very quick and they go out to see the patient. it s the whole rapid response element and that integrated working. they are providing almost a rapid response service, to people who are either becoming unwell or either beginning to have a crisis... The crisis ones tend to be where time is a factor where a package needs to be arranged as quick as possible. I find that the patient journey is a lot quicker by linking in with multi disciplinary teams. patients particularly like the fact that something is sorted quickly. I d say we are a lot easier to get hold of than the doctors we are more of a rapid response because we can get out to them if they need someone we can be there and leave the office straight away, whereas with GPs, they do have their surgeries to deal with first before they can get out to see people. It s a particular help for the palliative care patients where things can change quite quickly Healthcare professionals also emphasised how they felt the APFD service was solving problems by providing a service that provided a prompt effective intervention that filled a gap in the healthcare of elderly people. Healthcare professionals noted how this service had provided successful integrated rapid intervention for patients in crisis; something that they felt 20

21 had been lacking originally in older person s healthcare and had been causing issues for both healthcare professionals and patients. it works really well, and I think it is filling a gap for patients in crisis or are acutely unwell in Wirral who don t necessarily need to go into hospital. there s been a need for it. they re providing what I believe to be a huge gap on Wirral. It fills the gap because social services can t respond quick enough. It plugs gaps by using resources that we as GPs probably haven t tapped into as well as we could. A Specialist Service Healthcare professionals spoke of the importance of the APFD being a specialised service with nurses/healthcare providers who are experienced in maintaining older patients within community settings, which they felt resulted in a better quality of patient care. GPs spoke of the difficulty they faced when attempting to co-ordinate packages of care for patients with complex needs, and felt that the APFD had alleviated this pressure by successfully and competently meeting patient needs by arranging care packages through liaising with available services. Healthcare professionals spoke of how they felt the patient s needs were better met by the experienced staff within the APFD who had the skills to manage care for the patient, and those who referred into the service spoke of how they felt confident that their patient s needs would be met effectively. As a result of the skill and experience of those within the APFD service, GPs also felt that they were better supported. If you have people experienced in managing patients in the community the patient s needs are better met. it s about the right level of skills within the team, because you ve got nurse practitioners working in the team so they ve got that higher level of skill so they can actually manage any medical emergency; they ve got the skills to be able to assess that. you need that high level of communication skill the calibre of nurse as well [in the APFD team] you need a lot of experience to be in this job [APFD service], you need a lot of community background, and you need the hospital knowledge as well. [the APFD service] s ability to work with other services in the community. they [the APFD service providers] know how to contact day sitters and things you just tend to speak to the nurse who is going out to assess the patient, and she ll coordinate for us. You have a discussion with someone and you know you have the confidence that that problem will be sorted. I feel confident that there will be a response fairly quickly depending on the level of urgency. 21

22 The reality is, as GPs we didn t have the skills to assess as far as nursing residential homes, all the actual care requirements I think this has provided the expertise to back us up. sometimes the GPs don t always have a solution or the GPs can t respond as quickly it s not always the GPs that are in the best place to find the solutions Recommendations/suggestions In addition to highlighting that more staff would be helpful due to increased demand, some felt that at times other health professionals relied upon the APFD service too much, with some healthcare professionals recommending clearer boundaries as to what the APFD service criteria was. The only disadvantages I d say are some of the health professionals relying on us too much to sort things out that aren t really our criteria. One of the problems is the boundaries I think also there is the overlap with social care and social services so I think one of the disadvantages can be that those established services actually sometimes pulling back a bit or not doing as much as they could do because there is the APFD service. Sometimes they just pass it onto the APFD service rather than doing it themselves. Other healthcare professionals involved in delivering a service with the APFD service mentioned how they felt it would be beneficial for other services to be able to respond as quickly as the APFD service. they re going in and meeting the immediate need in that they can respond quickly; what you need is all the other services around them, they need to have a rapid access element so we can respond as quickly. Healthcare professionals spoke of the increased workload of due to the expansion of the APFD service, and one healthcare professional recommended that a system where nursing and residential homes could notify the APFD service of their availability would save the APFD service time and resources as they currently contact services in Wirral to determine their availability for patients. I think if there was a system whereby the nursing homes, residential homes and also possibly even care agencies alerted to their availability/notified to their ability, it would be easier. Furthermore, one health care professional noted that the APFD was in a unique position to be able to provide intelligence about poor discharges, which could potentially help to inform health policy. The CCG can actually get intelligence from the service about the discharge process, and poor discharges, which might be helpful from a commissioning and a contracting point of view. 3.2 Family interviews The main themes that emerged from the data were perceptions of service need, service response, impact on patient, impact on family members, service experience, perceptions of what would have happened without APFD service, and recommendations. 22

23 3.2.1 Perceptions of service need All family members described why they needed to use the service, and spoke of the strain that they had been under whilst trying to meet the care needs for their family member who became unwell. All family members spoke of feelings of helplessness when their family member became unwell, and some emphasised how they were unsure of what to do having never experienced such a dilemma before. Many of the participants elaborated that they had experienced significant difficulty in accessing services for support for themselves and the patient, with five of the seven family members interviewed expressing dismay at the service that they received before the APFD service intervened. These factors in turn resulted in increased pressure and strain for carers and also led to feelings of further isolation for some. [patient] was falling through cracks that s why [patient] got so damaged because there was no one on [patient] s case when I tried to get the name of someone on [patient] s case I couldn t. we kept not being able to get through to someone who would admit to being in charge of the case.with [patient] s condition very clearly worsening I didn t have anybody I went downhill as well. it was horrendous [patient] really wasn t very good. I was very frightened we were getting just more and more tired we really didn t know what on earth to do because we knew [patient] was going downhill. we were definitely a family in need we d never experienced anything like that before. Some family members also described the significant strain of having to also care for additional members of the family who were dependent upon care from the person who had become who had become unwell (e.g. their partner/significant other). This resulted in some families struggling to support two different people at the same time with significant care needs. I was under a lot of strain with X [patient] in the condition that X [patient] was in, trying to look after X [patient] we were very, very worried but we also had to look after Y [patient s dependent] who is severely disabled. So they took X [patient] into hospital but Y [patient s dependent] is blind, and X [patient] is Y s [patient s dependent] carer after five and a half weeks, they sent X [patient] out with us trying to cope as best we could. Well X [patient] just was getting worse Service response All participants placed particular emphasis on the rapid response of the APFD service, often speaking of how the team had intervened at a critical point and provided much needed support and intervention, which seemed to result in high levels of satisfaction. As participants had experienced significant strain trying to support their ailing family member, the rapid response of the APFD service had made a large impact for them as carers. Similarly, as some family members experienced difficulty accessing services and support for their family member whose health was declining, the rapid intervention of the APFD service had provided them with much needed relief and support that they felt they had been lacking. 23

24 Furthermore, participants felt that the rapid response provided had prevented the situation from deteriorating further, and also prevented the patient s condition using the service from worsening. Once we knew about the service, everything kicked into place straight away. [Service provider] intervened, and made it all happen. they transformed the situation. [Service provider] getting [patient] from her terrible position here into the care system in a timely manner. They were very rapid with their response Impact on the patient The APFD service provided interventions which significantly impacted upon the five patients. The APFD service provided assessment, increased care packages within the individual s home (which was also offered to patient s dependents), rapid access nursing beds and respite placements to support patients with twenty-four hour care, and also arranged long term care placements when it was necessary. For three patients, the APFD had intervened and patients had then avoided a hospital admission, with patients being managed within the community in respite residential/nursing placements. For one patient who was admitted to hospital on numerous occasions, significant other/carers spoke of how the APFD service intervened on two separate occasions when their family member was in hospital and how on these occasions, the service facilitated a quicker discharge and arranged a temporary care placement to help the patient recover. For one patient, the APFD arranged respite and whilst in respite the patient became unwell and was admitted to hospital. After the patient was discharged, the APFD then arranged a long term care placement as they had developed significant care needs. Five of the seven family members interviewed felt that the timely intervention and the support of the APFD service had prevented an acute crisis for the patient and had prevented the situation from becoming worse. These family members felt the interventions that the APFD provided for patients had prevented acute crises whereby the patient did not need to go into hospital for care. The other two family members noted how the patient was not at any point admitted to hospital, but was instead supported within their home environment by the APFD supporting the patient with an increased care package. the admissions prevention team got [patient] out [of hospital]. [The APFD service] did provide that link for getting immediate care. [The APFD service] took [patient] out of danger really, because from what I can see social services don t really act on things terribly quickly. [The APFD service] made a very, very big difference in [patient] s life, and certainly on all of us. [Patient] had a very positive experience and I think [patient] enjoyed all the interaction with the staff. 24

25 [Service provider] made all the necessary phone calls to get [patient] into a safe place, where [patient] was being fed, bathed if necessary, tablets given and all the levels of care [patient] needed at that time to prevent her becoming worse. The nursing home got [patient] back on their feet In one instance, family members noted the large impact of the service upon the patient s dependent, who was able to go and visit the patient (who was receiving respite care) in a nearby local residential setting, which consequently provided the patient, the patient s dependent and the significant other/carer with great comfort. This patient was then able to return home after ten days as their health had vastly improved with respite care. once we got X [patient] to the nursing home, we were able to let Y [patient s dependent] go in and see X [patient] it had a very positive impact on [patient s dependent] because [patient s dependent] had been very frightened. Another patient who was provided with respite nursing care was also able to return home for a period of time as they had recovered to a better state of health. In one instance, after a patient wished to return home after just two days of respite residential care, the APFD service arranged for an increased care package at home so that the patient s and carer s wishes could be fulfilled. This patient also returned home after their respite had ended. Similarly, when a family member wanted to arrange a long term care placement at a different location, the APFD service arranged for an increased care package at home until they could arrange a transfer, so that the carer s wishes could be fulfilled. For three patients, after time, the APFD service arranged for a long term care placement when their care needs increased and could no longer be met at home Impact on the family When describing the impact that the APFD service haw upon carers, family members emphasised the quality of support that was provided by the team, and the relief they felt as a result of the high standard of care of those within the service. All participants interviewed spoke of struggling to provide support for their ailing family member who was in crisis, and highlighted how the intervention provided by the APFD service had been critical in preventing further crises for both the family and the patient. The APFD service provided a successful intervention for the family by liaising with other services, increasing packages of care at home, facilitating hospital discharges, enabling access to other services (e.g. physiotherapy for rehabilitation), arranging temporary respite placements for patients, or in some instances arranging for a long term placements in a residential/nursing setting. the impact [of the service] was remarkable. It was just a huge relief. Huge. The Admissions Prevention was a life line for us : it lifted us out of a very tricky situation it just took away a lot of worries When we were intersectioned by them; it was brilliant, because what we wanted was [patient] to be safe with someone.they came round and got on the floor by [patient] and spoke to [patient], looked [patient] in the eyes, it was very moving, and said you might have to go and live somewhere else, do you understand? it s been like a cushion really between getting things arranged with social services to seeing where [patient] should be. 25

26 they saved me from what I was going through. it certainly took a lot of strain off my family. [Service provider] just took the pressure off us really it was a huge help. It was clear that the APFD had provided a high impact service, whereby all family members interviewed expressed gratitude for the support that they had received and spoke of the large difference they felt the service had made in their lives. I had a wonderful experience; it was a wonderful experience that service, to me, was phenomenal That whole service I can t praise it enough. I really can t the help that they gave me and [patient] Brilliant. It was fantastic... I ve got a lot of praise for them they were very good they did a very good job. I was very, very impressed with them. they were absolutely fantastic I couldn t have asked for more really. that was the best service that I had out of everything. I was very, very impressed with all the things that they could put in place Perceptions of life without the APFD service All family members spoke of the large impact the APFD service had had upon their lives, and explained how they felt they did not know how they would have coped without the support APFD service. For them, the service had been crucial and had intervened at a critical point, and they expressed dismay at the thought of being without the service that the APFD service provided. I don t know how as a family we would have coped [without the APFD service] I honestly look back now and I don t know what I would have done [without the APFD service], I didn t have anybody if I didn t have that [APFD service] I don t know what would have happened. Because I must admit I went downhill as well. Participants also felt that without the service and intervention provided by the APFD team, the situation would have deteriorated even more and their family member (patient) would have become very critically ill. One family member spoke of how she felt her family member 26

27 would have died without the APFD service. Another family member spoke of how without the service people would end up in hospital. I don t think the nursing home or any retirement home would have acted as quickly without [service provider] s direction. If it hadn t been for [service provider] and the admissions prevention team it might have been another month or two before [patient] actually got assessed with [patient] s condition very clearly worsening I actually think if [service provider] hadn t intervened I suspect that X [patient] may have died. That s how ill I felt that [patient] was. I was very frightened of [patient] actually dying in the house. [without the APFD service] a lot more people would probably finish up back in hospital and may be too weak to go home but not actually have a clinical need to be in hospital Service experience: Communication and support All participants spoke of the regular communication that they had had with the APFD team, which had a positive impact upon them as carers. Participants explained that if they needed to speak to somebody they could, and of how those in the service would always respond quickly and helpfully. Family members placed particular emphasis on the importance of being able to communicate regularly with members of the APFD team which had enabled their concerns and experiences to be heard. Family members appeared to receive support from the APFD service which they felt was an extremely important aspect and significant advantage of the service. This support seemed to provide them with comfort and reassurance at a particularly difficult time and also further increased their satisfaction with the service. If I felt that I just couldn t cope anymore, I could ring them and just tell them what had gone on and just bounce everything off them and it was that in itself was worth its weight in gold. To have somebody whenever you rang the office there was always somebody there. if we had a reasonable query that we didn t know what to do with that particular instance there were times when we rang [service provider] s office up, and [service provider] always rang us And it was good because we knew there was a person there who could sort a problem out for us. [Service provider] always rang us. [Service provider] gave us her office number and her mobile number, and answered and was on the case and she then remained in the picture. Just somebody listening that makes all the difference. it was soothing really to know [service provider] was on your side, and understanding the situation in a way that I don t think social services do. We knew they were there if we needed them [The advantage of the APFD service] was the support, it really was. 27

28 We didn t know how to handle it at all we needed somebody to talk to Quality of service providers Participants spoke of the staff involved in the delivery of the APFD service with high very regard, highlighting the high quality of support they had received from those involved in the delivery of the service. Family members placed particular emphasis upon the knowledge and experience of the staff, explaining how they had a very good understanding of how to effectively co-ordinate care for the patient, which resulted in a smoother, more seamless journey for patients and their carers. Often family members felt helpless and were unsure how to proceed, and those within the service were then able to provide family members with advice and moral support. You feel as though you are in expert hands [Service provider] guided us in the right direction. But it was only really though her that we really started to understand what it was all about because we just didn t know at all. [Service provider] knew which home would suit, and which type of care, that knowledge is a huge advantage, it s very beneficial she understands how systems are in place. It s reassuring to have somebody who deals with people all the time who are elderly, who gives you that sort of moral support in knowing that you are making the right decision. [Service provider] took all that on, and it was interesting to know that at least someone was coming in with experience to deal with a person in [patient] s position. Participants also spoke of the wider staff in the APFD, highlighting their positive experience and further commending the staff, accentuating the quality of service and support they had received from the staff, and how they felt the APFD service provided a compassionate, patient centred approach that made a significant difference. All of them that I came across with that facility were absolutely wonderful, and very caring, and very compassionate about what they were doing. [Service provider] did a good job and she has a good department. there was the NHS, there was social services, there was the visiting nurses and there was the Admissions Prevention group all dealing with X [patient]; of whom the Admissions Prevention group was far and away the most incisive and informed. I have been really impressed with [Service provider] they are the hands on people, the ones showing the compassion. [Service provider] was, very kind, a very kind person and very thorough [Service provider] s team; they were very good. [APFD service] was the best service that I had. [Service provider] s approach was just more humane I think dealing with [patient] they [APFD service] just come in at a different angle they re more interested in the health and wellbeing of someone it seems. 28

29 Responsibility Family members spoke in detail of how they felt the APFD service provided a seamless journey for them by successfully co-ordinating care and service for patients, and also by APFD team member taking on responsibility of this co-ordination. Participants felt this was a particular advantage of the service, as the service consisted of nurses with knowledge and experience of service and service co-ordination for the elderly; these nurses were also then able to assume responsibility by overseeing the patient s care. This provided carers with substantial relief as they explained they were unsure of what to do and felt very helpless, which resulted in participants expressing their gratitude for the APFD team taking responsibility in the situation. This was especially significant for those who had been trying to access services before APFD intervention and had experienced difficulties. [Service provider] understood that it was a process that had several stages and she was willing to and able to be responsible for that whole sequence. [Service provider] was just wonderful really because she just took over helping me to find the right accommodation to get my mum in. [Service provider] showed leadership because she s a nurse, she s not a doctor but she showed more leadership that the doctor s I spoke to. I saw some leadership with [Service provider]; someone who was prepared to take on a leadership role. [Service provider] s a very good liaison person, and kept us in the picture and helped us out, especially with getting things moving. [Service provider] s good, there was no two ways about it. [Service provider] just took it took the responsibility away from us and guided us in the right direction. there isn t that kind of oversight, that s what we felt was missing but [Service provider] filled the gap for us with that one. And we kind of nick named [service provider] wand waver we did call her the waver of the wand because that is what happened. When participants were speaking of their experience of the staff involved, it became apparent that in addition to providing significant other/carers with support and information, those involved in the delivery of the APFD service had also provided a service as an advocate, by providing advice and also by attending meetings with family members on their behalf. [Service provider] came with me to the meetings at the hospital to make sure I understood it and I was understanding it right [Service provider] was there every step of the way. [Service provider] supplied us with questions to ask which was really useful. [Service provider] gave us information on how to deal with things Recommendations/suggestions All participants explicitly stated that they felt the APFD as a service had no disadvantages, and were all very satisfied with the service that they had received. Participants spoke of how they wished they had known about the service sooner, with some recommending that there 29

30 should be increased awareness of the service so people would know to seek out the APFD service in the event of such crises. In addition to increased awareness, participants spoke of how they would like to see the service expanded as they felt the service was very important and needed, and also was of high impact. [Service provider] and her services they deserve all the money they can be given! Well I can t think of any disadvantages other than now knowing about it; so more awareness would be fantastic. You could have three [service provider] s you would get a lot done! I hope it [the APFD service] doesn t stop. Just don t lose that service! Because it s one of the best services Case studies Two cases studies of the APFD service were chosen to illustrate the impact of the APFD service upon the patient journey and the impact of the service upon family members. In each case study, the APFD provided different interventions for each patient that had a large impact on both the patient and their family members. The first case study illustrates the preventative interventions provided by the APFD that prevented further hospital admission and the support provided by the service to the family and patient. The second case study illustrates the facilitated discharge interventions provided by the APFD that reduced hospital length of stay and the support the service provided for the family with a transition into a long term care arrangement for the patient. Case study 1 Background The patient was elderly, living with a dependent who was disabled who the patient usually supported/cared for. The patient was admitted to hospital with chest pain, monitored for two days and then discharged. Upon arrival home, the patient became violently ill and was cared for by their family in the family home. Events leading to APFD intervention The patient was ill within their home, and was then relocated to the family s home for care, where they became increasingly unwell and suffered falls. The family felt unable to support the patient, on one occasion ringing an ambulance. The patient was not admitted into hospital due to an outbreak of the Norovirus on the ward. The family tried to arrange respite in a nursing home, but there were no temporary spaces available. The family were worried and frightened by the situation. When trying to increase the package of care for the person the patient cared for, the care agency recommended the family speak to their GP about the APFD service. The Senior Nurse of the APFD visited the family the following day. 30

31 Intervention The Senior Nurse from the APFD service assessed the patient, and on the same day arranged a two week stay at a local nursing home for the patient. The APFD service then organised a visit from an occupational therapist to assess the patient s home and provide adaptations for the house (e.g. higher toilet seat), which resulted in these adaptations being ready for when the patient returned home after their respite. The nursing home rehabilitated the patient to regain mobility. Outcome The patient was able to return to their own home within ten days where they lived with dependent, and their home was adapted to help them maintain their mobility. The patient was not at any point after APFD intervention admitted to hospital. Impacts Family members were extremely relieved, and the patient was able to receive the care they needed in order to regain their strength. The family was then able to care for the patient s dependent alongside their usual carers (care workers), whilst the patient recovered in the respite setting, which provided the dependent with the care they needed and reduced the strain on the family. The patient was very satisfied with the service they received, and the family members were also very satisfied. The patient s dependent was also very satisfied as they were able to visit the patient whilst they were in respite, as the home was wheelchair accessible, which the family member s explained provided the dependent with reassurance and relief. Case study 2 Background The patient was elderly and living alone, and had a history of falling and injuring themselves, and was later also diagnosed with dementia. All of the patient s close relatives lived abroad, and to care for the patient, the family had to travel back to the UK and support the patient within their home for weeks to months at a time. Events leading to APFD intervention number 1 The patient s health was declining and they were often falling and badly injuring themselves. The family had travelled from their home aboard, and were living with the patient trying to support them and were struggling to support the patients care needs. The family were worried by the situation. The patient was then admitted to hospital after a bad fall. The APFD service was then contacted. Intervention number 1 The APFD service facilitated a hospital discharge for the patient into a temporary nursing home placement. The nursing home cared for the patient until their health had improved. 31

32 Outcome number 1 The length of stay for the patient in hospital was significantly reduced. The patient was supported with a timely discharge into a local nursing home where there care needs were met effectively and was then able to return home after a month as their health had improved. Impacts Family members were relieved, and were able to travel back abroad and return to their home. The family members were very satisfied. Events leading to APFD intervention number 2 After a period of time, the patient fell again and their health began to decline. The family again travelled back to the UK to live with and support the patient. The family were struggling to support the patient s care needs alongside the patient s care workers and experienced significant difficulty when trying increase support services for the patient through social services and the patient s GP, and were worried by the situation. The APFD service was then contacted. Intervention number 2 The Senior Nurse from the APFD service assessed the patient, and on the same day arranged for the patient to attend A&E due to the state of their health. The patient was admitted to hospital. After a week in hospital, the APFD service facilitated discharge for the patient into a rapid access bed in a nursing home. The APFD service then arranged a long term care placement due to the patients care needs. The APFD liaised regularly with the family to find a suitable care home they were happy with. Outcome number 2 The length of stay in hospital for the patient was significantly reduced again. The patient was supported with a timely discharge into a rapid access nursing bed, and then was supported from this setting into a long term placement in a local care home. Impacts Family members were very relieved that the patient s care needs were being met effectively and they also were comforted with the knowledge that the patient was in a safe environment being supported. The family members were very pleased with the support that the APFD service had provided. 32

33 4. Summary of Findings Difficulties faced by healthcare professionals and carers Healthcare professionals felt that an acute setting was detrimental to the elderly if their needs could be met within their community, suggesting that these settings can de-skill and result in institutionalisation and increased dependency. It was also felt that staffing levels within these acute settings are perhaps unable to provide the level of care that the elderly need in order to recover optimally. This finding supports previous research highlighting that a hospital admission can incur risks for elderly patients that can sometimes have a negative impact on patient outcomes (Lafont et al., 2011; Alzheimer s Society, 2009; Philp, 2007). A factor that seemed to be impacting upon the ability to provide alternative settings for the care of elderly patients was that prior to the APFD service, GPs felt that it was difficult for them to try and co-ordinate and access care for elderly patients who needed urgent support. Healthcare professionals noted how often, these patients ended up in hospital as services could not respond quick enough to provide an intervention. GPs also highlighted the difficulties they faced when attempting to co-ordinate packages of care for patients with complex needs. Similarly, other healthcare professionals noted how in some instances, GPs were not in the best place to find solutions and co-ordinate care in the community care for the elderly. Family members caring for the patient (and at times the patient s dependent) seemed to be impacted heavily as an indirect result of these difficulties experienced by healthcare professionals. The majority of carers interviewed had experienced difficulty accessing support services for themselves and the patient they were caring for, with five of the seven family members interviewed expressing dismay at the service they received before the APFD service intervened. As a result of this difficulty, carers appeared to experience increased strain and felt isolated and helpless. All carers expressed the strain they were under trying to meet the patient s care needs who was deteriorating, and at times meet the care needs of other family members. This finding appears to lend support to previous research documenting how often an emergency hospital admission for an older person can be due a combination of circumstances involving social or caring responsibilities (Age UK, 2012). A lack of knowledge of the services available for the elderly was apparent with responses from family members, with all interviewees speaking of feelings of helplessness when their significant other/family member became unwell. Most elaborated that they were unsure of what to do having never experienced such a situation before. Many family members said that they were unaware of what services were available, and spoke of how they wished they had known about the APFD service sooner. Service accessibility and rapid response: filling a gap GPs explained how they would spend a long time trying to trying to access alternative care for their patients, which often ended up as failed attempts (with patients being admitted to hospital) as services could not respond quick enough to patients urgent social and care needs. All healthcare professionals noted that an advantage was the accessibility of the service and its rapid response and assessment of patients and carers in crises. They felt that this response enabled a successful timely intervention that avoided a hospital admission, delivered higher patient satisfaction and resulted in a quicker patient journey. The service and its rapid response made a significant difference to GPs who highlighted the positive impact that the service was having upon their workload. Many healthcare professionals emphasised that the service fills a gap for patients in crisis who are acutely unwell who do not need to be admitted to hospital by providing a timely intervention at a critical point to prevent the situation from deteriorating. They also believed that the rapid response of the APFD service was especially important as they felt other services could not respond quickly enough in order to prevent acute crises for patients and 33

34 carers. The rapid response of the APFD service seemed to successfully address the problems that healthcare professionals initially raised as issues in the care of elderly patients with complex needs. Similarly, family members placed particular emphasis on the rapid response of the APFD service, speaking of how the APFD service had intervened at a critical point which had prevented the patient from deteriorating further and needing a hospital admission. Family members spoke of the difficulty they had experienced before intervention, as a result of trying to support the patient (and in some cases their dependent) and also as a result of delays in accessing support services. Therefore the rapid response element of the service appeared to have been of significant impact. Many family members spoke of how the APFD service transformed the situation and provided much needed support for them as carers. The service and its rapid response made a significant difference to family members, which seemed to deliver a high impact intervention. The finding that all interviewees felt that the APFD service provided an important, rapid response that prevented crises for the patient appears to support previous research documenting that enabling timely and appropriate interventions can reduce risk and enable the maintenance of independent living (Jerram, 2010; Mundy et al., 2003). These findings also suggest some support for previous research documenting that early interventions can help patients and their families enjoy a higher quality of life (Alzheimer s Society, 2009). Personalised care Healthcare professionals spoke of how the APFD service enabled patients to receive treatment how they prefer by providing personalised care that gives patients choices. Healthcare professionals involved in referring in the service spoke of the ability of the APFD service to provide holistic, person centred care, noting how the service was focused upon the long term management of patients. They also emphasised how those involved in the delivery of the APFD service are able and willing to listen and respond to the concerns of both the patient and their family, which enhanced the care of patients and provided them and their family members with comfort. Similarly, those involved in delivering the service noted that they actively wanted to involve family members in the patient s care so they were also supported and informed. The family members interviewed similarly spoke of how the APFD service had assessed patients and then provided an intervention based on the family s and the patient s needs. These interventions included increased care packages at home, rapid access nursing placements, respite placements in local settings, access to physiotherapy, facilitating support discharge from hospital, and long term care placements when necessary. Family members spoke of how the APFD service incorporated the patients and family members wishes/preferences. For example, when a patient was unhappy with a respite placement, with the consent of the family, the APFD service supported them back to their home environment and increased their care package. Family members also emphasised how the APFD service involved them in any decisions about the patients care. Those family members of patients who went into a long term care placement spoke of how the service had supported them during the transition, and provided them with guidance and advice. In accordance with the healthcare professionals emphasising how the APFD service listened and responded to the needs and concerns the patient s family; family members spoke of how they had had regular communication with the APFD service whereby their concerns and experiences were actively listened to. Family members spoke of service providers telephoning them of their own accord to ask for updates on their situation and to see if they could provide any further assistance or support. This finding support previous research highlighting that involving patients and carers in decision-making enables them to make 34

35 informed choices, and can also support the communication process between multiple agencies (Scottish Government, 2009; Department of Health, 2010). Family members also placed significant importance on the impact of the support they received from the APFD service, and the hands on, personalised, caring nature of the service. For them as family members, this personalised approach had provided them with much needed comfort at a very difficult time. Similar to the findings from the healthcare professionals suggesting the service focused upon the long term management of patients, family members also spoke of how they felt the service was very invested in the overall health and wellbeing of patients and their carers. This findings appears to support previous research suggesting that working carers and significant others involved in the patient s care ensures a seamless service, whilst avoiding repetition and harmful outcomes (Jerram, 2010). The APFD service appeared to be providing advice and guidance to family members who felt particularly helpless and unsure, which supports research recommending that that older patients and their families should be provided with advice to help them to be better informed (Philp, 2007). The APFD as a specialist service Healthcare professionals highlighted the importance of the APFD as a specialist service that was facilitated by nurses/healthcare providers who were experienced in caring for and coordinating services for the elderly. Those interviewed felt that this provided a better patient journey and provided a better quality of care. As GPs spoke of the difficulty they faced trying to co-ordinate care for an elderly patients whilst maintain their other duties, the APFD service appeared to solve this problem by co-ordinating care effectively for patients and also liaising with relevant services. As a result, GPs feel that they were better supported as healthcare professionals because of the service. All Healthcare professionals spoke of the APFD service being able to contact the relevant services and effectively co-ordinate patients care due to their expertise. It was also found that the APFD service was seen to pull together different strands of healthcare which resulted in a more integrated intervention for the patient that accessed all the areas of health care that were needed. These findings support previous research noting how the care of more complex, elderly patients requires careful coordination from professionals with experience and skill, who are able to make high quality clinical decisions in order to address complex care needs (Jerram, 2010; Mytton et al., 2012). Family members commended the knowledge and experience of the staff, noting how they felt as in they were in expert hands, which provided them with comfort and reassurance. As family members often felt helpless having never experienced such circumstances before, the knowledge and experience of those within the APFD service was emphasised. Family members also placed significant importance on APFD team members being able to be responsible for the co-ordination of services for the patient s healthcare. The ability of those within the APFD service to assume responsibility for the patient and effectively liaise with other services seemed to result in a smoother journey for patients and their carers. This finding supports previous research noting the benefits of integrated care for the management of older people and those with long term conditions (Jerram, 2010). This also supports research suggesting that an integrated care approach for patients with complex needs improves the experiences of users and carers and reduces the utilisation of hospital-based services, whilst enabling a cost-effective approach to care (The King s Fund, 2011; 2012). Furthermore, the ability to co-ordinate and liaise with other care services is also an important strategy that is recommended in order to reduce avoidable admissions and length of stay in hospital (Parker et al., 2002; The Kings Fund, 2012), which appears a fundamental aspect of the APFD service. Impact of the intervention on patient hard outcomes All healthcare professionals agreed that the APFD service prevented hospital admissions and helped to prevent acute crises for patients and their carers. Healthcare professionals also felt without the APFD service, not only would there be a large increase in hospital 35

36 admissions, they also felt that carers health conditions would be exacerbated and this could result in a hospital admission for also the patient s carer. They felt that the APFD service provides all that patients needs without a trip to hospital. Healthcare professionals also thought that the APFD service facilitated an early, more unified discharge process from hospital by providing integrated support for the patient. General practitioners involved in referring into the service admitted to having less experience of facilitating a discharge for their patients with the APFD service, noting they were more involved with preventing hospital admissions through the service. Family members of patients who had used the APFD service declared that the intervention provided prevented an acute crisis whereby the patient would have been admitted to hospital. For three of the five patients, the APFD intervened and prevented a hospital admission. For one of the five patients, the APFD facilitated an earlier discharge from hospital on two separate occasions. Three patients were able to return to their home environment after receiving respite nursing care in their community. For one patient, the APFD arranged respite and then supported the patient into a long term care placement. Similarly, if after a period of time if the patient s health declined significantly, the APFD then arranged a long term care placement (this occurred for three of the patients). The interventions provided by the APFD service resulted in patients needs being met within their community, providing a suitable alternative to a hospital admission and stay. The APFD service was able to provide care for patients in an alternative setting, with both healthcare professionals and family members expressing how this had negated the need for a hospital admission. This finding supports previous research illustrating that by responding quickly and providing suitable alternatives, an admission can often be avoided in acute situations (Purdy, 2010; The King s Fund, 2011; 2012). Similarly, those interviewed felt the APFD facilitated discharge on some occasions resulted in a shorter length of stay. This finding suggests support for previous research demonstrating that facilitated discharge planning is effective in reducing the length of hospital stay (Shepperd et al., 2009; The Kings Fund, 2010). 36

37 5. References Age UK. (2012). Right care, first time: Services supporting safe hospital discharge and preventing hospital admission and readmission. Accessed 06/02/2013 from Alzheimer s Socity (2009). Counting the cost: caring for people with dementia on hospital wards. Accessed 05/02/2013 from Blunt, I., Bardsley, M. and Dixon, J. (2010). Trends in emergency admissions in England : is greater efficiency breeding inefficiency London: Nuffield Trust. Department of Health. (2008). Health and care services for older people: Overview report on research to support the National Service Framework for Older People. Accessed 05/02/2013 from Department of Health. (2010). The handbook to the NHS Constitution for England. Accessed 05/02/2013 from ce/dh_ Department of Health. (2012). National evaluation of Department of Health's integrated care pilots. Accessed 06/02/2013 from ce/dh_ Exemplar project submission (2011). Admissions Prevention and Facilitated Discharge service. Accessed 05/02/2013 from Henwood, M. (2006). Effective partnership working: a case study of hospital discharge. Health & Social Care in the Community, 14 (5), pp Holmas, T. H., Kjerstad, E., Frode, K. and Luras. (2007). Long term care and hospital length of stay for elderly patients. 6th World Congress: Explorations in Health Economics Paper. Available at SSRN: Holmas, T. H., Islam, M. K. and Kierstad, E. (2012). Interdependency between social care and hospital care: the case of hospital length of stay. European Journal of Public Health (Epub ahead of print). Jerram, S. (2010). The transfer of care of frail older people for community health and social support. Accessed 05/02/2013 from id=12:goodpractice&itemid=106 The Kings Fund (2010). Avoiding hospital admissions. Accessed 05/02/2013 from The Kings Fund. (2011). Emergency bed use: what the numbers tell us. Accessed 05/02/2013 from 37

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39 Witherington, E. M. A., Pirzada, O. M. and Avery, A. J. (2008). Communication gaps and readmission to hospital for patients aged 75 years and older: observational study. Quality and Safety in Health Care, 17, pp

40 Authors: Rachel Lavin, Hannah Timpson Centre for Public Health Research Directorate Faculty of Health and Applied Social Sciences Liverpool John Moores University 2nd Floor Henry Cotton Campus Webster Street Liverpool L3 2ET Tel: +44 (0) Web: 40